FINANCIAL DISCLOSURE AFFIDAVIT

1 413-1, 424-a; Art. 236-B, 240In the Matter of a Proceeding for Support(Commissioner of Social Services, Assignor, onbehalf of, Assignee) FINANCIAL , PetitionerDISCLOSUREAFFIDAVIT-against-, RespondentNotice: You are required to attach to this form the following documents:A current and representative paycheck stub;Copies of your most recently filed state and federal income tax returns;A copy of the w-2 wage and tax statement(s) submitted with the returns;the provision of insurance, health care, dental care, optical care, prescription drug andother pharmaceutical and health- related benefits for the child(ren) for whom support issought, including the costs for adding the child(ren) to such ,at:Information relating to all accident, life and health insurance plans available to you for*FAMILY COURTOF THE STATE OF NEW YORKCOUNTY OFDocket #:Family File #.

2 **, the herein, residingPetitionerRespondent, being duly sworn, depose and say that thefollowing is an accurate statement of my income from all sources, my liabilities, my assets and my networth, from whatever sources, and whatever kind and nature, and wherever situated:1 Unless ordered confidential, pursuant to Family Court Act 154-b, because of a risk that DISCLOSURE would place thehealth, safety or liberty of the party at risk. See Form GF-21 and GF-21a, available at DISCLOSURE AFFIDAVIT [Form 4-17 (8/2010)]Page 1 of 7I. INCOME FROM ALL SOURCES: The correct amount of the child support obligation is presumedto be a percentage of income as defined by law.

3 The percentages are set forth in Addendum A. Otherpertinent information is set forth in Addenda B and C. List your income from all sources as follows:A. Wages and Salaries (as reportable on Federal and State income tax returns):1. Employer and address2. Hours worked per week3. Gross salary/wages4. Deductionsa. Social Security (FICA) Taxc. New York State Taxb. Federal Taxe. Other payroll deductionsBi-weeklySemi-monthlyWeeklyMon thlyAnnuald. NYS/Yonkers Tax5. Number of members in household6. Number of dependents7. Income of other members of householdper1.

4 Workers Compensation2. Disability Benefits3. Unemployment Insurance Benefits5. Veterans Benefits10. Food StampsNOTE: Attach information for additional employers on separate Self-Employment Income: (Describe and list self-employment income. Attach to this form the mostC. Interest/Dividend Income:recently filed Federal and State income tax returns, including all schedules.)D. Other Income/Benefits:4. Social Security Benefits6. Pensions and Retirement Benefits7. Fellowships/Stipends/Annuities8. Supplemental Security Income (SSI)9.

5 Public AssistanceFinancial DISCLOSURE AFFIDAVIT [Form 4-17 (8/2010)]Page 2 of 7perperperperperperperperperperE. Income from other sources: (List here and explain any other income including, but not limited to,non-income producing assets; employment ''perks'' and reimbursed expenses to the extent thatthey reduce personal expenses; fringe benefits as a result of employment; periodic income;personal injury settlements; non-reported income; and money, goods and services provided byrelatives and friends.)II. ASSETS: The Court can consider the assets of the custodial parent and/or the non-custodialparent in its award of child support.

6 List your assets as follows:a. Savings account (Name of bank:)b. Checking account (Name of bank:)c. Automobile(s). (Year and make:Loan information:c.) have health insurance coverage through:MedicaidEmployer or organizationPrivate purchase''Child Health Plus'' program; my monthly premium isI do not have health insurance coverage. (If this box is checked, skip to section B.)medicaldental1. My coverage includes:prescription drugsopticalother health care services or benefits (specify):per2. The cost of the insurance paid by me isd. Residence Other real estate Other assets.

7 (For example: stocks, bonds, trailers, boat, etc.)g. Driver's, professional, recreational, sporting and other (Address:and permits held. (Provide name of issuing agency, license numberand attach a copy if possible) : Attach to this form any information as to any additional DEDUCTIONS FROM INCOME: The Court allows certain deductions from income prior to applyingthe child support percentages. List the deductions that apply to you as follows:a. Unreimbursed employee business expensese. Public Assistance and Food Stampsf. Supplemental Security Incomeg.)

8 NYC/Yonkers Income Taxh. FICA* Attach to this form a copy of the appropriate Court Maintenance actually paid to spouse not a party to this action *c. Maintenance actually paid to spouse who is a party to this actiond. Child support actually paid on behalf of non-subject child(ren) * HEALTH INSURANCE, UNREIMBURSED HEALTH-RELATED EXPENSES, CHILD CARE,EXPENSES, EDUCATIONAL EXPENSES AND LIFE AND ACCIDENT INSURANCE POLICIES: Aspart of the child support obligation, parents shall be directed to provide health insurance coverage, pay apro-rated share of the cost or premiums to obtain or maintain the health insurance coverage, a pro-ratedshare of unreimbursed health-related expenses, a pro-rated share of child care expenses and in theCourt's discretion educational expenses.

9 The Court may direct you to purchase and maintain life and/oraccident insurance benefits or assign benefits on existing policies for the benefit of your children. Listyour information as follows and cross out or delete inapplicable provisions: FINANCIAL DISCLOSURE AFFIDAVIT [Form 4-17 (8/2010)]Page 3 of 73. The person(s) covered by my insurance is/are:4. My policy number is5. Coveragedoesdoes not presently include my child(ren). The additional costto me to include my child(ren) would be: (Specify cost for each type of benefit. If benefit isunavailable, so indicate.)

10 PerMedical:Optical:perperDental:perPresc ription drugs:Other Health Services or Benefits (specify):per6. The name and address of my primary (and secondary) health insurer is/are:7. My primary (and secondary) health plan administrator is/are: (Indicate name, address andtelephone number of contact person for employer or organization.)8. There aremedicaldentalprescription drugsopticalother health care benefits (specify):available to the child(ren) through an individual who is not a party to this action. This individualis: (indicate name and relationship)benefitsperThe cost is:B.